BEFORE ME, the undersigned Notary,
___________________________________________________ [name of Notary before whom affidavit is sworn], on this _________________
[day of month] day of
_________________ [month], 20____, personally appeared
___________________________________________________
[name of
affiant], known to me to be a credible person and of lawful age, who being by me
first duly sworn, on ________ [his or her] oath, deposes and says:

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